Q&A on Medicare’s End-of-Life Care

End-of-life medical care has come under sharp review recently as policymakers grapple with whether health-care professionals should be reimbursed for talking to patients about their treatment options.

Planning for such care is fraught with difficulty. No one wants to discuss death and the infirmity that often surrounds it, but such discussions with doctors and families are critical to ensuring people receive the treatment they prefer if they are unable to communicate their wishes when the time comes. (See Patrick’s newsletter, “Dying in America: A Necessary Conversation.”)

About 3 in 4 of the 2.5 million people in the U.S. who die every year are 65 and older, making Medicare the largest insurer of health care provided during the last year of life. About 25% of what Medicare spends for health care is on services during beneficiaries’ last year of life. The cost is so high because many elderly people several serious and complex conditions.

Other considerations besides cost factor into end-of-life planning and determining public policy for it. About 9 in 10 adults, according to Kaiser Family Foundation (KFF), a nonprofit health research and policy outfit, say they would prefer to receive end-of-life care in their home if they were terminally ill, but data show that only about 1 in 3 Medicare beneficiaries dies at home.

KFF, which is not affiliated with the provider/insurer Kaiser Permanente, has compiled a Q&A about Medicare’s current role in end-of-life care and advance care planning. Here are some excerpts:

Q: What is “end-of-life care” and does Medicare cover it?

A: End-of-life care encompasses all health care provided to someone in the days or years before death, whether the cause of death is sudden or a result of a long-term illness. For people older than 65, the most common causes of death include cancer, cardiovascular disease and chronic respiratory diseases.

Medicare covers health-care services beneficiaries may receive until they die, including care in hospitals and other facilities, home health care, physician services, diagnostic tests and prescription drug coverage through a separate Medicare benefit.

Many of these services may be for curative or palliative (symptom relief) purposes, or both. Beneficiaries with a terminal illness are eligible for the Medicare hospice benefit not included under traditional Medicare (more about hospice services below).

Q: What is “advance care planning” and does Medicare cover it?

A: Advance care planning involves multiple steps designed to help individuals: understand the health-care options available for end-of-life care; determine which types of care best fit their wishes; share their wishes with family, friends and their physicians.

In some cases, patients who have already considered their options might need only one advance care planning conversation with their physician. But some beneficiaries might require several conversations with their physician or other health professionals to clearly understand and define their end-of-life wishes.

Medicare covers advance care planning only under limited circumstances. Neither physicians nor beneficiaries are reimbursed by Medicare for advance care planning if it’s the sole purpose of the doctor visit. To be covered under Medicare, such discussions must occur either as part of appointments made for other reasons (such as illness or injury) or during the one-time “Welcome to Medicare” visit that may occur within a beneficiary’s first 12 months of Medicare enrollment.

The agency that runs Medicare (the Centers for Medicare and Medicaid Services, or CMS) included advance care planning as a voluntary service when the Affordable Care Act (ACA, or Obamacare) established annual wellness visits. But the provision was retracted before it could take effect in 2011 because the CMS said it did not have sufficient “opportunity to consider prior to the issuance of the final rule the wide range of views on this subject held by a broad range of stakeholders.”

Q: Are policymakers, such as CMS or Congress, considering changes in Medicare’s coverage of advance care planning?

A: Yes. Last year CMS said it will consider the possibility of allowing physicians to bill Medicare separately for advance care planning in the future. CMS highlighted billing codes submitted by the American Medical Association to acknowledge advance care planning services as of 2015, but did not approve their use for Medicare reimbursement. CMS said it will consider whether to pay for these services in 2016, after it “has had the opportunity to go through notice and comment rulemaking.” This discussion is anticipated in August.

Before passage of the ACA, bogus claims were made during the 2008 election that including advance care planning in Medicare coverage beneficiaries would result in government “death panels,” or people making end-of-life decisions for Medicare beneficiaries. That nonsense persisted even after the ACA passed.

Now, two bills have been introduced in Congress pertaining to advance directives and end-of-life care. One would provide coverage under Medicare for advanced illness planning and care coordination services, including discussions about treatment options and patient preferences, to Medicare beneficiaries who have a serious progressive or life-threatening illness. The other would establish Medicare and Medicaid coverage for advance care planning consultations between patients and doctors or other health-care professionals.

Q: What’s an advance directive?

A: An advance directive is written instructions that reflect a patient’s wishes for health care to guide medical decision-making in the event he or she is unable to speak for himself or herself. Generally, it’s the result of advance care planning and often involves a living will, which defines the medical treatment that patients prefer if they are incapacitated, or designation of a certain person as a medical power of attorney. Advance directives fall under state regulation, and the required forms for formal advance directives vary from state to state.

About 4 in 10 Americans 65 and older do not have advance directives or have not written down their own wishes for end-of-life medical treatment.

Q: Are health-care facilities, such as hospitals or skilled nursing facilities, required to keep records of Medicare patients’ advance directives?

A: The Patient Self-Determination Act, which took effect in 1991 requires hospitals and skilled nursing facilities to ask each patient on admission if he or she has an advance directive and record its existence in the patient’s file. Facilities may not require a patient to create an advance directive before providing treatment or care, and Medicare patients are not required to have one before they receive care.

Recent surveys show that among long-term care patients, those receiving care in a facility (such as a nursing home or hospice facility) are more likely to have advance directives.

Q: Does Medicare cover hospice care? How many Medicare beneficiaries use hospice?

A: Yes. For terminally ill Medicare beneficiaries who choose palliative over curative treatment, Medicare covers an array of services, including nursing care, counseling, palliative medications and some respite care to assist family caregivers. Most often, hospice care is provided in patients’ homes.

Medicare patients covered by the hospice benefit have little to no cost-sharing liabilities for most hospice services.

To qualify for hospice coverage under Medicare, a physician must confirm that the patient is expected to die within six months if the illness runs a normal course. If the Medicare patient lives longer than six months, hospice coverage may continue if the physician and the hospice team re-certify the eligibility criteria.

In 2013 nearly half of all Medicare beneficiaries who died used hospice. Hospice care accounts for about 10% of traditional Medicare spending in beneficiaries’ last year of life.

Medicare Advantage plans do not cover hospice care, so if a Medicare Advantage enrollee receives hospice care, it’s covered under traditional Medicare (Parts A and B).

A: Palliative care focuses on managing symptoms and providing comfort to patients and their families, no matter how old a patient is or what kind of coverage he or she has; it’s not restricted to people with terminal illnesses, but commonly used among people living with serious, complex and chronic illnesses, such as cancer, heart disease, general pain or depression.

Nearly half of all Medicare beneficiaries have four or more chronic conditions for which palliative care services might be appropriate, either in combination with or instead of curative treatment.

Q: Has the Institute of Medicine (IOM) made any recommendations regarding advance care planning and end-of-life care?

A: The IOM recently released a comprehensive report, “Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life,” that included five recommendations to increase the quality of end-of-life care and improve the ability for patients to choose their own treatment plan.

Briefly, they are:

coverage of comprehensive care for patients with advanced serious illnesses who are nearing the end of life by both government and private health insurers;

development of standards and ways to measure clinician-patient communication and advanced care planning, with insurance reimbursement tied to performance of the standards;

regulations to establish financial incentives for integrating medical and social services for people nearing the end of life, including electronic health records that incorporate advanced care planning; and

widespread efforts to inform the public about the benefits of advance care planning and the ability of individuals to choose their own course of treatment.

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